An unwelcome scar

When he was ten years old, PT sustained a blow to a pigmented lump on his left antecubital fossa. The lump had been present since birth. After this trauma, the lump became swollen and extremely tender to the touch. The swelling and tenderness not only persisted but became more painful over the next three weeks, so PT’s mother took him to see his GP, who referred him to Mr W, a general surgeon.

Mr W saw PT and Mrs T in his outpatient clinic two weeks later. After examining the still swollen and painful lesion and eliciting the patient’s history, he felt that an urgent excision biopsy was needed to eliminate the possibility of malignancy.

Mrs T was, in Mr W’s opinion, an over-anxious mother and he did not want to add to her anxieties by mentioning the possibility of cancer, so he recommended an excision merely to eliminate the cause of PT’s pain. He described the procedure, telling Mrs T that it would be a relatively straightforward operation that could be carried out as a day case and PT would be “as right as rain” in no time.

The possibility of any untoward outcomes – namely, scarring and nerve damage – was not discussed because Mr W considered these to be self-evident. Moreover, as he did not think that PT, at age ten, was competent to understand the implications of the proposed procedure, he addressed himself only to Mrs T.

Mrs T gave consent to the surgery, which Mr W carried out two days later. The operation was uneventful, and the histology report fortunately showed only a cavernous haemangioma with no sign of malignancy.

Subsequent to the operation, PT developed an unsightly hypertrophic scar at the site of the surgery and an area of localised numbness on his forearm. When he reached his teens, he became increasingly self-conscious about the appearance of the scar and, eventually, when he was 18, underwent revision surgery.

Shortly after this, he brought an action against Mr W alleging that he had failed to warn of the possible complications, claiming compensation for the cost of revision surgery and for pain and suffering.

As it was evident that neither PT nor his mother had been warned of either of these known complications of the surgery, the case was settled.

Learning points

• Doctors are rarely, if ever, successful in relying on therapeutic privilege as a reason for not explaining a material risk to a patient. 
• Mr W made a false assumption that the risks of scarring and nerve damage were self-evident. Although he might reasonably have expected Mrs T to realise that there would be some scarring, it was unlikely that she would have expected a hypertrophic scar to develop, or that she would have been aware of the possibility of nerve damage occurring. 
• If Mr W had been open and transparent from the start he might have avoided these problems, if he had explained his concern about excluding malignancy.
• Even if they lack the maturity or competence to consent to treatment, children should be included in decision-making to the extent that they are able to understand.
• For more information about consent to treatment, download one of our booklets or factsheets.